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6ETT1ER-RYAN INC. GR Job# 20-641524 <br /> L, b <br /> Spill Bucket Testing Report Form UU <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. TheA ip e d 2p?m and <br /> printouts from tests (if applicable), should be provided to the facility owner,'operator for submittal to the local ¢ ggency. <br /> 1.FACILITY INFORMATION <br /> [[Date <br /> ility Name: Arco SS 5450 Date of Testing: 7/26/2016 <br /> ility Address: 1617 W. Fremont,Stockton,CA <br /> ility Contact: Sarah Samuels Phone: 360-526-3917 <br /> Local Agency Was Notified of Testing: <br /> ame o ocaAgency Inspector (if-present during testin7: <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-Ryan Inc.,6805 Sierra Court Suite G Dublin.Ca.94568 Ph.#925-551-7555 <br /> Technician Conducting Test: Elodio Sanchez <br /> Credentials:(1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(Spec) <br /> License Number: 220793 ICC Tech Number: 8126818-UT <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hvdrostatic Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87-1 2 87-2 3 91 <br /> Number,Stored Product,etc. Fill Fill Fill <br /> Bucket Installation Type: Direct Bury Direct Bury Direct Bury Direct Bury <br /> a Contained in Sump x Contained in Sump x Contained in Sump Contained in Sump <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 15" IS" 15" <br /> Wait time between applying <br /> 10min 10min lomin <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:30 9:30 9:30 <br /> Initial Reading(Ri): 11 1/4" 11 1/2" 11 114" <br /> Test End Time(Tf): 10:30 10:30 10:30 <br /> Final Reading(Ro 11 1/4" 11 1/2" 11 1/4" <br /> Test duration(Tf-Ti): 1 hr 1 hr 1 hr <br /> Change in Reading(Rf-Ri): 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> Test Results: x Pass Fail x Pass Fail x Pass Fail Pass Fail <br /> Comments-(include information on repairs made prior to testing,and recommended follow-up forfailed tests) <br /> CERTFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements <br /> Technician's Signature: ..O� .0--®" Date: <br /> (1) State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br /> may be more stringent. <br />